Only 10% of alcoholics develop end-stage liver disease. What separates those who develop advanced liver disease from those who do not is not clear.

The risk of developing cirrhosis is increased by coexisting hepatitis C virus infection

Pathogenesis of Alcoholic Liver Disease

The mechanism whereby alcohol produces different liver lesions is poorly understood. Fatty change may be due to increased production and decreased use of fatty acids in the liver cells

For the development of alcoholic hepatitis, fibrosis and cirrhosis, the production of toxic metabolites c during the conversion of acetaldehyde to acetate may be responsible. In addition, the immune reaction to liver cells altered by alcohol may also be involved.

Ethanol is principally metabolized by hepatocyte alcohol dehydrogenase to acetaldehyde, which is further metabolized by aldehyde dehydrogenase to acetate. Faster formation of acetaldehyde by alcohol dehydrogenase or decrease in clearance of acetaldehyde by variants of aldehyde dehydrogenase could increase the exposure of hepatocytes to highly reactive acetaldehyde.

Treatment

Abstinence from alcohol

Nutritional support

Prognosis

Alcoholic fatty liver has a good prognosis. Complete resolution occurs after cessation of alcohol intake.

Alcoholic Hepatitis

Alcoholic is an inflammatory lesion characterized by infiltration of the liver with leucocytes, liver cell necrosis, and alcoholic hyaline deposition. Alcoholic hepatitis develops in approximately 10% of those with long-term daily ethanol consumption.

Clinical Features

This varies from asymptomatic patient to mild illness to fatal liver cell failure.

Prognosis

In milder cases, clinical recovery can occur completely. However, repeated bouts of alcoholic hepatitis may lead to irreversible progressive liver injury, abstinence from alcohol can reduce long term morbidity and mortality.

Marked hyperbilirubinemia, elevated creatinine, elevated prothrombin time, ascites and encephalopathy are associated with poor short term prognosis.

Overall, alcoholic hepatitis carries 35%-45% mortality.

Alcoholic Cirrhosis

These patients may not have any symptoms or may present with end-stage liver disease and portal hypertension including ascites, encephalopathy, or variceal bleeding.

Laboratory findings are deranged as in other liver diseases- elevated prothrombin time, abnormal liver function tests and hypoalbuminemia.

All patients with suspected alcoholic cirrhosis should undergo an upper endoscopy to look for esophageal varices.

A patient with decompensated [ascites, encephalopathy] liver cirrhosis requires liver transplantation. The patient should be referred to a rehabilitation center and six months of abstinence is necessary for getting listed for transplant.

Prognosis

The prognosis of cirrhosis depends whether it is compensated or decompensated

In compensated alcoholic cirrhosis

90% 5- year survival who stop alcohol consumption

70% 5-year survival if they continue alcohol consumption.

Patients with decompensated cirrhosis who continue alcohol consumption have a 5-year survival rate of only 30%.